Provider Demographics
NPI:1285676205
Name:LAVALLEY, GARY JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAY
Last Name:LAVALLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:HENRYETTA
Other - Middle Name:EYE
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:900 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-4252
Mailing Address - Country:US
Mailing Address - Phone:918-652-2345
Mailing Address - Fax:918-652-2537
Practice Address - Street 1:900 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4252
Practice Address - Country:US
Practice Address - Phone:918-652-2345
Practice Address - Fax:918-652-2537
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK410003624OtherRAIL ROAD MEDICARE
OKP00626582OtherRAILROAD MEDICARE
OK100764630AMedicaid
OKU34127Medicare UPIN
OK410003624OtherRAIL ROAD MEDICARE
OKP00626582OtherRAILROAD MEDICARE